7.4 Pain, Palliative Care & End-of-Life

7.4 Pain, Palliative Care & End-of-Life

Assessing and Managing Pain

Accurate pain assessment is the foundation of effective management. For patients who can communicate, self-report using a Numeric Rating Scale (0-10) or the FACES scale is the gold standard — pain is what the patient says it is. For nonverbal, sedated, or intubated patients, self-report is not possible, and behavioral observation tools take over:

• Critical-Care Pain Observation Tool (CPOT) — scores facial expression, body movements, muscle tension, and compliance with the ventilator (or vocalization if extubated)
• Behavioral Pain Scale (BPS) — scores facial expression, upper-limb movement, and ventilator compliance

A critical exam point: vital signs (heart rate, blood pressure) are not reliable stand-alone indicators of pain — they can be elevated by many factors besides pain, or blunted by sedatives and beta-blockers, and should prompt further assessment with a validated tool rather than being treated as confirmatory of pain by themselves.

Multimodal analgesia is now the preferred strategy in critical and progressive care: combining opioids with non-opioid adjuncts — acetaminophen, NSAIDs when not contraindicated, ketamine, gabapentinoids, and regional/local techniques — controls pain more effectively while reducing the total opioid dose needed and, with it, opioid-related adverse effects such as respiratory depression, oversedation, and constipation (a scheduled bowel regimen should accompany any ongoing opioid therapy). Chronic pain in progressive care patients often coexists with acute pain from a new illness or procedure, and both must be addressed in the treatment plan rather than assuming a patient with a chronic pain history is drug-seeking when reporting new or worsening pain.

Palliative Care vs. Hospice

These terms are frequently confused, and the distinction is directly testable:

The key distinguishing fact: palliative care has no prognosis requirement and does not require stopping curative treatment, while hospice specifically requires a limited prognosis and generally means curative treatment for the terminal condition has stopped. A patient can — and often should — receive palliative care consultation early in a serious diagnosis while still pursuing aggressive treatment.

Symptom Management at the End of Life

As patients approach death, several symptoms require specific, comfort-focused management rather than aggressive intervention:

• Dyspnea/air hunger — low-dose opioids reduce the sensation of breathlessness; positioning (usually more upright) and a fan directed at the face can help; oxygen is used for comfort, not to correct a lab value
• Terminal secretions ("death rattle") — pooled oropharyngeal secretions from an inability to swallow or clear them; managed with repositioning (often side-lying) and anticholinergic medications (scopolamine, glycopyrrolate, or atropine) to reduce secretion production. Aggressive suctioning is generally avoided as a primary intervention — it is often ineffective at the source of the sound, can be distressing to the patient, and is more disturbing to family at the bedside than the sound itself
• Terminal delirium — nonpharmacologic measures (quiet environment, reorientation, family presence) are first-line; low-dose antipsychotics may be used if delirium is causing significant distress
• Signs of impending death — mottling of extremities, Cheyne-Stokes respiration patterns, decreasing level of responsiveness, cooling of extremities, and decreased urine output are expected findings that should be proactively explained to family

Withdrawal of Life-Sustaining Treatment and Family Support

When the goals of care shift to comfort and a decision is made to withdraw life-sustaining treatment (such as terminal extubation or discontinuing vasopressors), the nurse's priority is ensuring comfort medications are available and ready to administer before the withdrawal begins, following the institution's protocol. Family and chaplaincy involvement, clear communication about what to expect, and continued presence at the bedside are central nursing responsibilities.

Holistic end-of-life care extends beyond the patient to family support and bereavement, and incorporates spiritual care consistent with the patient's and family's values — reflecting the Synergy Model's Caring Practices and Response to Diversity competencies that run throughout the Professional Caring and Ethical Practice domain, even though the clinical symptom management itself is scored under Clinical Judgment.

Advance Directives and Documented Goals of Care

Honoring a patient's previously expressed wishes is a core nursing responsibility whenever a critically ill patient can no longer speak for themselves. An advance directive (living will, healthcare power of attorney) and a POLST/MOLST (Physician/Medical Orders for Life-Sustaining Treatment) form, when available, translate a patient's values into actionable medical orders covering resuscitation status, mechanical ventilation, artificial nutrition, and hospital transfer preferences. The progressive care nurse verifies that current code status and treatment-limitation orders are documented and consistent with the patient's or surrogate's most recently expressed wishes, and raises a palliative care or ethics consultation early whenever the care team, patient, and family disagree about goals of care rather than allowing the conflict to persist unaddressed. Nonverbal patients nearing the end of life who cannot use standard self-report pain scales — including many patients with advanced dementia — may also be assessed with tools such as the PAINAD (Pain Assessment in Advanced Dementia) scale, which, like CPOT and BPS, relies on observed behaviors rather than self-report.